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T� APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address 7163 East Uyeda City Stockton Lot Size PM Owner's Name Chesney, Harold Address 7163 E Uyeda Phone 931,-2 80 Clark Well2024 E Charter Wa Contractor Address y License No,371.560�Phone 462-7676 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION;Q, PUMP INSTALLATIONX SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.�LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LN ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications TTT M Public ,1 =+s Er n-Other.1 , fl Delta Depth of Grout Seal Type of Grout I I ltrigation _ Approx. Depth I 1 Eastern Surface Seal Installed by, _ Repair Work D'onef , ❑' Type of Pump --H.P.- State Work Done Chanae to GalyaniZ d� Well Destruction' ' ` ❑f Well-Diar>Lteter Sealing Material (top 50') Pressure Tank.+�u ' Depth, ' K Filler Material (Below 50') if TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIRlADDITIONI I DESTRUCTION i 1 (No septic system permitted if public sewer is .--. .w < -ti-- .. �:�: w. _. available within 200 feet.1 c Installation will serve: Residence_ Commercial_ Other c Number of living units: I Number of bedroolff _�`__ "Ct%a doter of soil to a depth°af 3 feet: Water"table depth SEPTIC TANK ❑ TypelMfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ -: � Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS ( I Depth Size Number SUMPS El Distance to nearest: Well Foundation Property Line ' DISPOSAL PONOS CI 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. i i Home owUlficensed agent's signature certifies thefollowing: "I certify that in the performance of the work for which this permit is issued, I shall not employ ach manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaturecertifies trtify that in a perfor anceof the work for which this permit is issued,I shall employ persons'.subject to workman's compensa- tion lawsThe applifor aqui n ctio Complete drawing on reverse side. Signed X Title: Sec--Tres Date: 31 Mar 88 FOR DEPARTMENT USE ONLY { 0� Application Accepted by Date ✓ ' Area Pit or Grout Inspection by Date Final Inspection by Date. Additional Comments: A ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8335-6385 Applicant • Return all copies to. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, htk., CA 95201 if FEE it INFO 41 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY t DATE PERMIT-NO. F f Xn xn + EH 13-26 EH 13-24 IREY.t 14 5) Wi a - _.:- :.. l� ( 00 i